Citation Nr: 18145914 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-15 467A DATE: October 30, 2018 ORDER Entitlement to a rating in excess of 20 percent for post-operative meniscectomy and ligament repair of the left knee is denied. Entitlement to a rating in excess of 10 percent for posttraumatic degenerative joint disease (DJD) of the left knee is denied. Entitlement to a separate 10 percent rating for left knee lateral instability is granted. Entitlement to a rating in excess of 10 percent for post-operative left knee scars is denied. REMANDED Entitlement to total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s left knee, post-meniscectomy and ligament repair, results in frequent episodes of “locking,” pain and effusion. His additional symptoms of lateral instability and pain with loss of flexion are compensated under different diagnostic codes. 2. The Veteran had posttraumatic DJD of the left knee with flexion limited to 100 degrees (at worst), with objective evidence of painful motion. His DJD of the left knee did not manifest in loss of extension to 10 degrees or greater, during the period on appeal. 3. The medical evidence of record supports that the Veteran has left knee instability, noted to be slight (0 to 5 mm) on all evaluations during the period on appeal. The preponderance of the medical and lay evidence does not demonstrate that his lateral instability is moderate or severe. 4. The Veteran has two post-operative superficial, non-linear scars on his left knee. During an October 2012 examination he reported that the two scars were tender to touch; however, during all examinations for the period on appeal the scars were stable and are static in size at approximately 30 sq.cm. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for left knee, post-meniscectomy and ligament repair, have not been met. 38 U.S.C. § 5107 (2014); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5260 (2018). 2. The criteria for a rating in excess of 10 percent for left knee posttraumatic DJD with painful motion (flexion) have not been met. 38 U.S.C. § 5107 (2014) 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code (DCs) 5003, 5260 (2018). 3. The criteria for a separate 10 percent rating for left knee slight instability have been met. 38 U.S.C. § 5107 (2014); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code (DC) 5257 (2018). 4. The criteria for a rating in excess of 10 percent for left knee post-operative scars have not been met. 38 U.S.C. § 5107 (2014); 38 C.F.R. § 4.118, Diagnostic Code (DC) 7804 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Navy from September 1968 to May 1970. These matters come before the Board of Veterans’ Appeals (Board) on appeal from September 2013 (scars) and November 2014 (increased knee ratings) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. In September 2015, the Veteran submitted a statement that he was forced to retire from his employment with the U.S. Postal Service due to his left knee disabilities. He submitted a letter from the Officer of Personnel Management that indicated he was found disabled for his position as a “mail city carrier” due to derangement of left knee and rotator cuff conditions. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (CAVC) held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. As such, the Board has added a claim of entitlement to TDIU, which will be remanded for additional evidence and opinion. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must consider the extent to which a veteran may have additional functional impairment beyond the limitation of motion objectively demonstrated, such as when the symptoms are most prevalent due to the extent of the pain and painful motion, weakness, premature or excess fatigability, and incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The rating schedule is intended to recognize actually painful, unstable, or malaligned joints due to healed injury as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Application of 38 C.F.R. § 4.59 is not limited to cases of painful motion in which there is a finding of arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Case law and VA guidelines anticipate that VA examiners will use information procured from relevant sources, including lay statements, to estimate additional functional loss during flare-ups of musculoskeletal disability. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). 1. Entitlement to a rating in excess of 20 percent for post-operative meniscectomy and ligament repair of the left knee, a separate 10 percent rating for instability, and a rating in excess of 10 percent for left knee DJD with painful motion and loss of flexion The Veteran is seeking increased ratings for his left knee disability. Service treatment records show that the Veteran suffered a torn medial collateral ligament and medial meniscus of the left knee following a fall on a ladder in service. He also had a strained anterior cruciate ligament and chronic instability due to trauma. An operative record noted that the Veteran had complete disruption of the medial collateral ligament with suggestion of a tear of the anterior cruciate ligament. Surgery was performed, repairing of the medial collateral ligament which had avulsed from its tibial insertion. He had a small tear in the anterior cruciate ligament, which had been stretched. The medial meniscus was excised. The Veteran re-injured his knee while on convalescent leave from the hospital by falling and placing partial unsupported twisting weight on the knee. Examination showed that one of the fixation staples had been pulled partially loose and was protruding under the skin. The staple was removed a few weeks later. Even after physical therapy, he had laxity of the anterior cruciate and the medial collateral ligament, considered “chronic instability” which rendered him unfit for further military service. Medical Evidence—Left knee ratings In May 2010, prior to the period on appeal, the Veteran was afforded a VA examination. In May 2010, he complained of throbbing, constant pain that was localized medially. It was noted that private physician, Dr. L.A.N., had diagnosed locked knee with osteoarthritis and possible torn medial meniscus. He had flare-ups once a week which would last up to three days. Standing increased pain. He stated he could walk up to a half-mile. He wore a knee brace on occasion and denied having any incapacitating episodes during the past 12 months. He walked with a limp favoring his left leg. On range of motion he had flexion to 120 degrees, but had extension limited to 20 degrees. His knee appeared to be “locked at this position. There appeared to be no increased loss of function with use due to pain, fatigue, weakness, lack of endurance or incoordination.” He had “some” “anterior instability and laxity.” He had medial tenderness, with no joint swelling or redness. He had a negative McMurry sign. X-rays showed 2 staples in the proximal tibia used to repair the medial collateral ligament. There appeared to be medial narrowing and possible loose joint body noted. He was diagnosed with posttraumatic DJD of the left knee with instability. The examiner provided an opinion that the Veteran was “experiencing a moderately severe to severe disability from his left knee condition.” In October 2012, again prior to the period on appeal, the Veteran was afforded another VA knee examination. He reported that his left knee “always had some pain the longer he would stand on it, the more it hurts.” His knee pain had increased in the past 5 years. His arthritis was very uncomfortable, his knee was stiff, especially after he gets off work. He stated that he could not bend it fully, unlike his right knee. He reported wearing a knee brace when working, to help with stability. He stated that in the last year he began using a walking cane. He reported his private physician (Dr. L.A.N.) did an arthrogram on the knee and said the Veteran had a torn meniscus and needed an operation. He reported flare-ups such that while he was at work, the knee hurt so bad (without medication) that it was difficult to put weight on it. On evaluation, his right knee range of motion was from zero to 130 degrees without objective pain. His left knee range of motion was from zero to 110 degrees without objective painful motion. After repeat testing, his right knee flexion increased to 135 degrees, and his left knee flexion increased to 120 degrees. His extension remained at zero, bilaterally. His functional impairment after repetitive testing was noted to be less movement than normal and pain on movement. He had tenderness to palpation of the left knee. He had 4/5 (active movement against some resistance) muscle strength in both knee flexion and extension on the left; normal on the right. He had left posterior instability +1 (0 to 5 mm). There was no history of patellar subluxation/dislocation. Regarding meniscal conditions, the Veteran was noted to have a meniscal tear with frequent episodes of joint “locking” and pain. He had a meniscectomy in 1969, with residuals of “chronic 24-hour pain and stiffness.” He stated he would “not know what to do if he did not have his pain medications and a knee brace.” Regarding functional impact, the Veteran reported working as a postal clerk and being required to stand “all day,” which effected his knees on a daily basis. “Standing, twisting, walking brings on pain.” He noted that his knee condition had worsened because his pain was now constant, and previously it would “come and go.” He stated he was unable to lift items above a certain weight, and had problems twisting or turning due to his knees. The Board notes that the February 2010 arthrogram provided by the Hughston Clinic (Dr. L.A.N.) showed an abnormal medial meniscus; the radiologist could not tell if it was a tear or a previous meniscectomy. “Secondly, he note[d] a loose body and thirdly, chondral changes of the femoral condyle.” The physician noted that they did not know whether the meniscus was taken out or partially taken out in his prior surgery, or whether this represents a new tear or degenerative changes. He had a loose body, which could “float around and jam the joint up,” and he had surface problems on the femoral condyle. “Probably part of this is trying to come loose and that could account for the popping. Popping comes from the meniscus. It comes from loose body. It also comes from the articular surface.” In June 2014, the Veteran filed a claim for increased rating for his left knee disability. A June 2014 record from the Hughston Clinic noted Veteran had a “prior ACL repair and staple removal while in the military service.” He reported daily pain that limited his everyday activities. He reported severe aching/throbbing left knee pain with weakness, swelling, catching/locking, popping/clicking, and radiation down leg. He had a limp and antalgic gait, but did not use any assistive devices. On physical examination he had genu varum deformity and swelling (with effusion). He had tenderness of the medial wall trochlear groove, the medial patellar facet, the medial femoral condyle, the medial joint line, and the medial tibial plateau. He also had tenderness of the medial patellar retinaculum and medial collateral ligament. His range of motion of his right knee was normal. His active range of motion of his left knee was from zero to 120 degrees. He had “1+ poss abd,” as well as edema and a positive Lachman’s test. His passive range of motion on the left was limited and pain was elicited by motion. Degree of limitation was not listed. He had normal strength bilaterally. The Veteran elected to proceed with an injection of Depo-Medrol to his left knee. He was assessed with primary osteoarthritis and knee pain. It was noted that he was in “desperate need of a left” total knee replacement. He had a “combination of DJD with ligamentous instability.” He was in severe pain from his knee and shoulder, and the treatment provider noted that he was “totally disabled.” In August 2014, the Veteran was again afforded a VA examination. The Veteran was noted to have undergone surgery on his left knee in 1969 with no further surgery to the left knee. He reported having been treated with pain medication and physical therapy “since 2010.” He complained of constant left knee pain, and “it pops and locks and the pain goes down [his shin] and sometimes it swells.” He did not report flare-ups that impacted the function of the knee. His right knee had a full, pain-free range of motion. His left knee had active motion from zero to 120 degrees, with objective pain at 120 degrees. His extension to zero also resulted in objective pain. He performed repetitive range of motion testing, with post-test flexion to 120 degrees, and extension to zero degrees. He had less movement than normal, excess fatigability, incoordination, pain on movement, swelling, deformity, and disturbance of locomotion of the left knee after repetitive use. He had tenderness to palpation of the left knee. He had normal muscle strength on flexion and extension of both knees. He had anterior instability of 1+ (0-5 mm) of his left knee. Other stability tests were normal. He did not have a history of recurrent patellar subluxation/dislocation. He did not have shin splints or other tibial and/or fibula impairment. He had a history of a semilunar cartilage condition, with frequent episodes of joint “locking,” pain, and effusion. The residual symptoms from his meniscectomy was listed as “pain, popping, swelling, locking.” He reported regularly using a left knee brace. The examiner marked that his knee conditions impacted his ability to work due to increased pain with walking and lifting during his employment with the US Postal Service. “It is less likely than not that pain, weakness, fatigability, and incoordination could significantly limit functional ability during flare ups or when the joint is used repeatedly over a period of time.” The examiner noted that the Veteran had “no decrease in range of motion during Deluca testing and no additional limitation due to pain, weakness, fatigability or incoordination.” In September 2015, the Veteran filed a notice of disagreement with the rating decision providing him with a continued 20 percent rating for his post-operative meniscectomy and a 10 percent rating for his DJD. He stated that he had “severe lateral instability, severe recurrent subluxation, and limitation of flexion.” He indicated he wanted a 20 percent rating for limitation of flexion. He reported he had to retire due to his knee. An October 2015 Hughston Clinic record noted that the Veteran was told he needed a total knee replacement and he was being seen to discuss his surgical options. He reported stabbing/aching/throbbing pain in both knees. Aggravating factors were lying down, walking, bending, squatting, moving from sitting to standing, going up and down stairs. Associated symptoms included weakness, swelling, catching/locking, popping/clicking, grinding, instability, and “radiation down leg.” On physical examination he had a normal gait, without limp, and could ambulate without an assistive device. He had genu varum deformity and swelling (effusion) of his left knee. He had tenderness of the medial joint line. His active range of motion was from zero to 100 degrees on the left. His passive range of motion on the left was listed as “normal.” His right knee active and passive motion was normal. Stability of his left knee was noted as “no laxity, subluxation, or ligamentous instability;” anterior and posterior drawer signs were negative, Lachman test was negative, and McMurry test and Apley’s compression were negative. X-rays showed evidence of osteoarticular abnormality with narrowing of the medial joint space, subchondral cysts medial tibial plateau, and osteophytes of the medial tibial plateau. He was assessed with osteoarthritis of the left knee. He wished to undergo “scope left knee” in mid-December; “knee arthroscopy.” An additional note included that the Veteran was seeking a left knee recheck after an ACL repair. He was noted to have retained hardware from a 1969 surgery. He had limited flexion and wanted a “scope, not total.” It was noted that he needed a total knee arthroplasty but he “refuse[d].” It was noted that he could not have an MRI due to retained metal. He had “instability and limitation of motion as above.” On his April 2016 substantive appeal, the Veteran stated that his last VA examination had been provided without the benefit of review of his records as the examiner’s computer was not allowing her to access his file. He argued he was entitled to an increased rating because his private physicians believed he needed a knee replacement. In October 2016, the Veteran was afforded another VA examination. He complained of pain with walking, with popping noted. He stated he needed a left knee replacement. He had constant pain, of a 6 out of 10, and was taking Hydrocodone. He reported left knee swelling roughly every 10 days. The functional loss/impairment was described as pain and swelling. He had normal range of motion of the right knee. He had left knee flexion to 120 degrees, and extension to 0 degrees. His passive range of motion for both knees remained the same. The range of motion itself did not contribute to functional loss. There was pain on flexion and extension, which caused functional loss. There was evidence of pain with weightbearing. There was localized tenderness/pain to the medial knee joint. There was no crepitus. The Veteran completed repetitive use testing of his right knee, with no functional loss. He completed repetitive use testing of his left knee, with no additional functional loss shown. The examiner noted that the Veteran was being examined immediately after repetitive use over time and pain, weakness, fatigability, and incoordination did not significantly limit functional ability after repeated use over a period of time. The examiner additionally noted that the Veteran was being examined during a flare-up and that there was no significant limit to functional ability due to flare-up symptoms. The examiner noted that additional contributing factors of disability were decreased range of motion, swelling, joint deformity, gait alteration, and interference with standing. His left knee had 4/5 (active movement against some resistance) muscle strength in both flexion and extension. His right knee had normal muscle strength. There was no muscle atrophy. The examiner selected that there was no history of recurrent subluxation or lateral instability. He had a history of recurrent effusion, with the notation “draining noted with surgery. Positive ballottement on examination.” The Veteran had normal right knee stability on testing. The Veteran’s left knee had 1+ (0-5 mm) anterior instability, and normal posterior/medial/lateral stability tests. The Veteran was noted to have a left knee meniscus (semilunar cartilage condition) resulting in meniscal tear, frequent episodes of joint “locking,” joint pain, and joint effusion. He underwent a left meniscectomy and ligament repair in 1969 with residual symptoms of pain and swelling. The Veteran regularly used a cane and occasionally wore a left knee brace. The Veteran’s conditions did not result in functional impairment that would be equally well served by amputation with prosthesis. X-rays showed left knee arthritis. The functional impact of his left knee disabilities on his employment were noted as “mild impact with walking noted.” In May 2017, the Veteran provided a statement that his knee was in “constant pain” and he could not “walk no it for a long period of time! Therefore, it is hard to work!” He requested another examination; however, he did not indicate that a prior examination was inadequate or that his symptoms had worsened since his examination roughly seven months prior. The Board does not find that remand for an additional examination is warranted. The 2014 and 2016 examinations included examination of both knees, repeat range of motion testing, statements regarding flare-ups and functional impact, and addressed his passive range of motion as well. The Veteran did not indicate that his left knee symptoms had worsened since his 2016 examination, and, again, the Board notes that his request for a new examination was only 7 months after his 2016 examination was completed. Range of motion testing did not indicate that the Veteran was close to meeting the criteria for a higher rating, as his extension remained normal (zero degrees), and his flexion was to 100 degrees (at worst), which is 55 degrees greater than that necessary for the next higher rating (20 degrees). Meniscectomy and ligament repair with “locking,” pain, effusion, and instability Initially, a June 1970 rating decision provided a 50 percent rating. This was noted to be a temporary 50 percent convalescent rating. This rating was decreased to 20 percent, effective August 1, 1971. These initial ratings were provided under Diagnostic Code (DC) 5257. A November 2014 rating decision listed the Veteran’s post-operative meniscectomy and ligament repair rating as 20 percent under DC 5258-5257. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Notably, as the Veteran’s 20 percent for his post-operative meniscectomy and ligament repair has been in place since 1971 it is protected. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, the selection of diagnostic codes or applicable rating criteria is not protected and may be appropriately revised if the action does not result in the reduction of compensation. See 38 C.F.R. § 3.951, 3.957. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). Diagnostic Code 5257 provides that an evaluation of 10 percent is assigned for slight recurrent subluxation or lateral instability. An evaluation of 20 percent is assigned when the impairment is moderate, and an evaluation of 30 percent is assigned when the impairment is severe. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of semilunar cartilage. Here, the Board finds that the evidence of record supports two separate ratings for the residuals of the Veteran’s meniscectomy and ligament repair. His 20 percent rating remains, and is protected, but will be addressed under DC 5258 for “Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion to the joint.” As was described in the medical evidence above, the Veteran’s knee continues to have frequent episodes of “locking,” pain, and effusion despite the service treatment records indicating that his meniscus was excised. Indeed, the symptoms described in DC 5258 accurately describe the Veteran’s residuals from his in-service meniscectomy and ligament repair. Providing the 20 percent rating under DC 5258 is appropriate and does not result in a change in rating for the Veteran for this disability. The Board will also add a separate 10 percent rating under DC 5257 (other impairment of the knee) based on slight lateral instability. This provides an overall greater rating for the Veteran’s knee while addressing all of his current symptoms. As shown in the medical evidence above, the Veteran has not been assessed with “lateral” instability or subluxation, as specifically addressed by DC 5257. Instead, he has consistently been found to have objective slight anterior instability. He has also subjectively reported the need for a knee brace due to feelings of instability. Although not “lateral,” the Board finds that assignment of a 10 percent under DC 5257 allows for the Veteran’s symptom of instability of his left knee to be adequately addressed. A recent CAVC decision highlighted that separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (DC 5260), limitation of extension (DC 5261), lateral instability or recurrent subluxation (DC 5257), and meniscal conditions (DCs 5258, 5259). See Lyles v. Shinseki, 29 Vet. App. 107 (2017). The Board finds that a rating in excess of 10 percent, under DC 5257, is not warranted as the Veteran’s anterior laxity is consistently described as slight. Although the Veteran subjectively wears a knee brace due to feelings of instability, the medical evidence outweighs his assertion that he has severe instability by noting he had 0 to 5 mm of laxity/instability during medical evaluation. The preponderance of the evidence is against finding for a rating in excess of 10 percent for instability. Although the Veteran is in receipt of the highest (only) rating under DC 5258, the Board notes that it was provided based on his symptoms. Although the record indicates that his meniscus was excised, and that therefore DC 5259 would be applicable, the Board finds that the 20 percent rating under DC 5258 is more applicable as related to his symptoms of frequent “locking,” pain, and effusion. Again, the 20 percent rating is also protected. Additional symptoms of instability and pain with motion are addressed in separate ratings under DC 5257 (instability) and DC 5003-5260 (pain with flexion). As the Veteran’s various symptoms are covered by other diagnostic codes, the Board does not find that extraschedular rating is appropriate for his post-operative meniscectomy and ligament repair of the left knee. The Board notes that the medical evidence has consistently stated the Veteran had a genu varum deformity. DC 5263 provides a 10 percent rating for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Although similar sounding (genu is Latin for knee), varum indicates an outward bowing of the knees (sometimes referred to as bow-legged), whereas recurvatum indicates a backward bend to the knee. As a backward bend to the knee would require hyperextension, the medication notations of zero degrees of extension show that he does not have hyperextension of the knee. As such, a separate rating for his genu varum deformity is not indicated by the DC. Posttraumatic DJD with painful motion A Veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 (which provides for a 10 percent rating for a noncompensable limitation of motion or painful motion of an affected joint) and 5257, provided that a separate rating must be based upon additional disability. Also, separate ratings may be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same knee, the limitations must be rated separately to adequately compensate for functional loss associated with the disability. Diagnostic Code 5260 pertains to limited flexion of the knee. Flexion limited to 60 degrees is noncompensable. A 10 percent rating applies when flexion is limited to 45 degrees. A 20 percent rating applies when flexion is limited to 30 degrees. A 30 percent rating applies when flexion is limited to 15 degrees. Diagnostic Code 5261 provides a noncompensable rating for extension limited to 5 degrees. A 10 percent rating for extension limited to 10 degrees. A 20 percent rating is provided for extension limited to 15 degrees. A 30 percent rating is provided for extension to 20 degrees. A 40 percent rating is provided for extension limited to 30 degrees. And a 50 percent rating is provided for extension limited to 45 degrees. Here, the Veteran is in receipt of a 10 percent rating for limitation of flexion to a noncompensable degree, with objective evidence of painful motion under DC 5003. DC 5003 does not provide for a greater rating for one joint with painful motion. The medical evidence does not support a rating in excess of 10 percent based on left knee DJD with limitation of motion. At worst, the Veteran’s flexion has been limited to 100 degrees. This is 55 degrees greater than a compensable rating under DC 5260. The Veteran’s lay statements to VA and private treatment care providers do not indicate flexion which would meet the requirements of 20 percent rating, which would require flexion limited to 30 degrees. The preponderance of the medical and lay evidence of record is against a finding of an increased rating based on limitation of flexion. A separate compensable rating for limitation of extension is not warranted. During the period on appeal, the Veteran’s extension has not been limited to 10 degrees. Prior to the period on appeal, in February 2010, the Veteran sought private treatment which noted that his range of motion was limited to 10 degrees (“extension”) and 90 degrees (flexion). The physician diagnosed locked knee. However, by the period on appeal, the Veteran’s flexion had returned to normal (zero degrees). The Veteran has not made any lay arguments regarding the inability to straighten his left knee, and the medical evidence does not suggest that he has limitation in extension. As such, a separate rating for limitation of extension is not warranted. 2. Entitlement to a rating in excess of 10 percent for post-operative left knee scars The Veteran contends that his post-operative scars should warrant a rating in excess of 10 percent. His notice of disagreement with the initial 10 percent rating did not provide any argument for a greater entitlement. The Board finds that entitlement to a rating in excess of 10 percent for post-operative left knee scars is not warranted. Diagnostic Code 7804 assigns ratings for scars that are unstable or painful. A 10 percent rating is assigned for one or two qualifying scars, a 20 percent rating for three or four qualifying scars, and a 30 percent rating for five or more qualifying scars. Note 1 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 indicates that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. See 38 C.F.R. § 4.118, Diagnostic Code 7804. Private treatment records from 2010 to 2016 do not include any notations of painful or unstable scars. On October 2012 scar examination noted the Veteran has two scars from his in-service knee surgery. He reported that both scars were tender to touch. Neither scar was unstable. One scar was located on the medial side of his left knee in a vertical pattern, and measured 14 cm x 2 cm. The second scar was located on the medial side of the left knee in a horizontal pattern and measured 4 cm x 0.5 cm. Both were superficial and nonlinear. There was a combined 30 sq. cm. area. The August 2014 VA examination noted that the Veteran had two scars that were not painful and/or unstable, and the total area of the scars was less than 39 sq. cm. The October 2016 VA examination included that the Veteran had two scars associated with his in-service knee surgery. There was no objective evidence that the scars were painful, unstable, or had aa total area equal or greater than 39 sq. cm. The scars were: 1) left medial patella, vertical, and nontender; measuring 14 cm x 0.3 cm, and 2) flat scar to left medial patella, horizontal, nontender, measuring 5 cm x 0.2 cm. As the Veteran only has two scars he does not meet the criteria for a greater rating under DC 7804 without a showing that the scars are unstable. The Veteran has not reported that the scars are unstable, and, more importantly, the medical care providers and examiners have not found that his scars are unstable. Additionally, the scars do not warrant a compensable rating under other scar diagnostic codes due to their location and size. See 38 C.F.R. § 4.118, DCs 7800-7805. REASONS FOR REMAND 1. Entitlement to total disability based on individual unemployability is remanded. The Veteran has argued that his left knee disorders resulted in his early retirement due to being unable to continue his employment with the U.S. Postal Service. He has provided statements from the Office of Personnel Management that he is disabled, in part, due to his knee. He also has private treatment records that show that included the opinion that the Veteran is disabled, in part, due to his knee. With the additional 10 percent provided in this decision, the Veteran still does not meet the schedular requirement for entitlement to TDIU. On remand, the Veteran should be provided with a TDIU formal claim to complete, and his case should be forwarded to the Director of Compensation for initial review for extraschedular TDIU. The matter is REMANDED for the following action: 1. Provide the Veteran VA Form 21-8940 and request he provide details regarding his employment history and education. An appropriate period of time should be allowed for response. 2. After the TDIU claim form is returned, refer the case to the Director, Compensation Service for extraschedular consideration for TDIU. Include a full statement as to the Veteran’s service-connected disabilities, employment history, educational history, and all other factors having a bearing on the issue. (Continued on the next page)   3. Thereafter, readjudicate the Veteran’s claim. If the decision remains adverse to the Veteran, he should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel